Once-daily omeprazole/sodium bicarbonate heals severe refractory reflux esophagitis with morning or nighttime dosing.

BACKGROUND: Morning dose or twice-daily proton pump inhibitor (PPI) use is often prescribed to heal severe reflux esophagitis. AIM: Compare the effect of single dose morning (control arm) versus nighttime (experimental arm) omeprazole/sodium bicarbonate (Zegerid(®)) (IR-OME) on esophagitis and gastroesophageal reflux symptoms. METHODS: Adult outpatients with Los Angeles grade C or D esophagitis were allocated to open-label 40 mg IR-OME once a day for 8 weeks in a prospective, randomized, parallel design, single center study. Esophagogastroduodenoscopy (EGD) and validated self-report symptom questionnaires were completed at baseline and follow-up. Intention-to-treat and per-protocol analyses were performed. RESULTS: Ninety-two of 128 (72 %) eligible subjects participated [64 (70 %) male, mean age 58 (range 19-86), median BMI 29 (range 21-51), 58 C:34 D]. Overall, 81 (88 %) subjects healed [n = 70 (76 %)] or improved [n = 11 (12 %)] erosions. There was no significant difference (morning vs. night) in mucosal healing [81 vs. 71 %, (p = 0.44)] or symptom resolution [heartburn (77 vs. 65 %, p = 0.12), acid regurgitation (82 vs. 73 %, p = 0.28)]. Prevalence of newly identified Barrett's esophagus was 14 % with half diagnosed only after treatment. CONCLUSIONS: Once-daily IR-OME (taken morning or night) effectively heals severe reflux esophagitis and improves GERD symptoms. Results support the clinical practice recommendation to repeat EGD after 8 weeks PPI therapy in severe esophagitis patients to assure healing and exclude Barrett's esophagus.

An insight into the microbiome of the Amblyomma maculatum (Acari: Ixodidae).

The aim of this study was to survey the bacterial diversity of Amblyomma maculatum Koch, 1844, and characterize its infection with Rickettsia parkeri. Pyrosequencing of the bacterial 16S rRNA was used to determine the total bacterial population in A. maculatum. Pyrosequencing analysis identified Rickettsia in A. maculatum midguts, salivary glands, and saliva, which indicates successful trafficking in the arthropod vector. The identity of Rickettsia spp. was determined based on sequencing the rickettsial outer membrane protein A (rompA) gene. The sequence homology search revealed the presence of R. parkeri, Rickettsia amblyommii, and Rickettsia endosymbiont ofA. maculatum in midgut tissues, whereas the only rickettsia detected in salivary glands was R. parkeri, suggesting it is unique in its ability to migrate from midgut to salivary glands, and colonize this tissue before dissemination to the host. Owing to its importance as an emerging infectious disease, the R. parkeri pathogen burden was quantified by a rompB-based quantitative polymerase chain reaction (qPCR) assay and the diagnostic effectiveness of using R. parkeri polyclonal antibodies in tick tissues was tested. Together, these data indicate that field-collected A. maculatum had a R. parkeri infection rate of 12-32%. This study provides an insight into the A. maculatum microbiome and confirms the presence of R. parkeri, which will serve as the basis for future tick and microbiome interaction studies.

Choice of a stable set of reference genes for qRT-PCR analysis in Amblyomma maculatum (Acari: Ixodidae).

Quantitative real-time reverse transcriptase polymerase chain reaction (qRT-PCR) is a widely used laboratory tool to quantify mRNA levels of target genes involved in various biological processes. The most commonly used method for analyzing qRT-PCR data are the normalizing technique where a housekeeping gene is used to determine the transcriptional regulation of the target gene. The choice of a reliable internal standard is pivotal for relative gene expression analysis to obtain reproducible results, especially when measuring small differences in transcriptional expression. In this study, we used geNorm, NormFinder, and BestKeeper programs to analyze the gene expression results using qRT-PCR. Five candidate reference genes, glyceraldehyde 3-phosphate dehydrogenase (GAPDH), beta-actin, alpha-tubulin, elongation factor 1-alpha, and glutathione s-transferase, were used to evaluate the expression stability during prolonged blood-feeding on the vertebrate host. These five genes were evaluated in all life stages of Amblyomma maculatum (Koch) as well as in the salivary gland and midgut tissues of adult females to determine which are the most stably expressed gene for use in qRT-PCR studies. Beta-actin is the most stably expressed gene in salivary glands and midguts ofA. maculatum, and throughout all developmental stages both Actin and GAPDH were found to have the most stable expression with the lowest degree of variance. We recommend the use of beta-actin and/ or GAPDH as reference genes for qRT-PCR analysis of gene expression in A. maculatum.

Lessons Learned During Prolonged Care of Combat Casualties by a Minimally Manned Surgical Team.

In the current deployed environment, small teams are dispersed to provide damage control surgical capabilities within an hour of injury. Given the well-developed evacuation system, these teams do not typically have a significant patient hold capability. Improved understanding of the shortfalls and problems encountered when caring for combat casualties in prolonged care situations will facilitate improved manning, training, and equipping of these resource-limited teams. We present the case of two critically injured soldiers who were evacuated to a 10-person split Forward Surgical Team (FST) during a weather system that precluded further evacuation. The casualties underwent damage control procedures necessitating temporary abdominal closures. The FST had to organize itself to provide intensive care significantly longer than traditional timelines for this role of care. Additionally, most team members had scarce critical care experience. An after-action review confirmed that most team members felt that they had not received adequate pre-mission training in postoperative intensive care and were not comfortable managing ventilated patients. In the current mature theaters of operations, there are robust evacuation capabilities, and presentations of scenarios like that are rare. However, as combat casualty care becomes increasingly austere and remote, small surgical teams need to train and be equipped to provide care outside of normal operation and doctrinal limits, including robust team cross-training. Incorporating principles of the prolonged care of combat casualties into the training of military surgeons will improve preparedness for these challenging situations.

Staff perceptions of military chemical-biological-radiological-nuclear (CBRN) air-purifying masks during a simulated clinical task in the context of SARS-CoV-2.

Air-purifying full-face masks, such as military chemical-biological-radiological-nuclear masks, might offer superior protection against severe acute respiratory syndrome coronavirus 2 compared to disposable polypropylene P2 or N95 masks. In addition, disposable masks are in short supply, while military chemical-biological-radiological-nuclear masks can be disinfected then reused. It is unknown whether such masks might be appropriate for civilians with minimal training in their use. Accordingly, we compared the Australian Defence Force in-service chemical-biological-radiological-nuclear Low Burden Mask (AirBoss Defense, Newmarket, Canada) with polypropylene N95 masks and non-occlusive glasses worn during simulated tasks performed by civilian clinicians in an Australian tertiary referral hospital intensive care unit. After brief training in the use of the Low Burden Mask, participants undertook a simulated cardiac arrest scenario. Previous training with polypropylene N95 masks had been provided. Evaluation of 10 characteristics of each mask type were recorded, and time to mask application was assessed. Thirty-three participants tested the Low Burden Mask, and 28 evaluated polypropylene N95 masks and glasses. The Low Burden Mask was donned more quickly: mean time 7.0 (standard deviation 2.1) versus 18.3 (standard deviation 6.7) seconds; P = 0.0076. The Low Burden Mask was rated significantly higher in eight of the 10 assessed criteria, including ease of donning, comfort (initially and over a prolonged period), fogging, seal, safety while removing, confidence in protection, and overall. Visibility and communication ability were rated equally highly for both systems. We conclude that this air-purifying full-face mask is acceptable to clinicians in a civilian intensive care unit. It enhances staff confidence, reduces waste, and is likely to be a lower logistical burden during a prolonged pandemic. Formal testing of effectiveness is warranted.

Obesity and general pain in patients utilizing family medicine: should pain standards call for referral of obese patients to weight management programs?

BACKGROUND: Accredited medical care organizations are expected to assess pain levels in their patients. Appropriate responses to high pain levels have not been specified. DESIGN: This study was a retrospective analysis of information abstracted from medical records of 673 adult patients utilizing family medicine. Pain was measured using a scale ranging from 0 to 10. Scores of 7 and above were judged to represent high levels of pain. Multiple logistic regression was used to test the relationship between body mass index (BMI) and general pain, after adjustment for co-morbidity, physical limitations, and demographic characteristics. RESULTS: Multiple logistic regression analysis revealed that, in comparison with patients with normal body mass, patients with BMI greater than 35 had higher odds of experiencing pain scored 7 or over after adjusting for physical limitations, co-morbidity, age, and gender (adjusted odds ratio [AOR] = 1.89, P = .03). Odds ratios also were significant for subjects with any (vs none) physical limitations (AOR = 1.91, P = .01) and for men relative to women (AOR = 0.65, P = .04). co-morbidity, common diagnoses, and moderate BMI scores were not independently related to high pain levels. CONCLUSIONS: In our sample of patients utilizing family medicine, BMI greater than 35 is a risk factor for elevated pain scores. This relationship appears to be independent of orthopedic consequences of obesity. Referral to weight management programs might be useful as a quality indicator for obese adults reporting high levels of general pain.

A patient-centered decision rule for referral of patients to weight-loss programs.

BACKGROUND: The obesity epidemic threatens to shorten life expectancy and reduce the quality of life for large segments of the population. The purpose of this study was to develop a decision rule for referral to a weight-loss program on the basis of the relationship between body mass index (BMI) and self-rated overall health. METHODS: We employed a patient satisfaction survey of family medicine patients treated in Mayo Clinic in Rochester, Minnesota, linked with medical record information, to test the theory that, in primary care patients, BMI exhibits an inverse and independent relationship with overall self-rated health after adjusting for age, gender, marital status, and cigarette smoking. Interviews were linked to medical records for 679 adult patients. RESULTS: Adjusting for age and other confounders using multiple logistic regression analysis revealed that overweight (BMI = 25-30 kg/m(2)) was not a risk factor for poor self-rated health and only BMI above 35 kg/m(2) was significantly related to poor overall health (adjusted odds ratio = 0.33, confidence interval = 0.17-0.64, P = .0012). CONCLUSIONS: Quality improvement programs should monitor whether obesity is being addressed in clinical settings. A patient-centered decision rule for addressing obesity could involve referral of patients whose BMI is above 35 kg/m(2) to weight management programs, monitoring of patients whose BMI scores are between 30 and 35 kg/m(2), and encouragement of patients whose BMI is above 25 kg/m(2) to avoid weight gain.

Impact of open-access scheduling on realized access.

Open-access or advanced-access scheduling, which opens the clinic calendar to patients without requiring them to schedule far in advance of the visit, is being introduced in primary care for the purpose of improving access. None of the evaluations reported to date have measured differences in actual visits that might be associated with different scheduling systems. The purpose of this study was to compare utilization of visits to primary care providers for patients served by an open-access clinic with utilization patterns of patients served at clinics not using open-access scheduling. We hypothesized that the odds that a continuing patient received more than one primary care visit would be greater in the clinic where open-access scheduling was in use than in comparison clinics. Our study provides mixed support for the hypotheses. After adjustment for case mix, stable chronic patients treated in open-access clinics may sometimes have greater odds of receiving two or more preventive care visits. However, these effects do not occur in all clinics, suggesting that other clinic characteristics may overcome the effects of open-access scheduling.

A study of ticks and tick-borne livestock pathogens in Pakistan.

BACKGROUND: As obligate blood-feeding arthropods, ticks transmit pathogens to humans and domestic animals more often than other arthropod vectors. Livestock farming plays a vital role in the rural economy of Pakistan, and tick infestation causes serious problems with it. However, research on tick species diversity and tick-borne pathogens has rarely been conducted in Pakistan. In this study, a systematic investigation of the tick species infesting livestock in different ecological regions of Pakistan was conducted to determine the microbiome and pathobiome diversity in the indigenous ticks. METHODOLOGY/PRINCIPAL FINDINGS: A total of 3,866 tick specimens were morphologically identified as 19 different tick species representing three important hard ticks, Rhipicephalus, Haemaphysalis and Hyalomma, and two soft ticks, Ornithodorus and Argas. The bacterial diversity across these tick species was assessed by bacterial 16S rRNA gene sequencing using a 454-sequencing platform on 10 of the different tick species infesting livestock. The notable genera detected include Ralstonia, Clostridium, Staphylococcus, Rickettsia, Lactococcus, Lactobacillus, Corynebacterium, Enterobacter, and Enterococcus. A survey of Spotted fever group rickettsia from 514 samples from the 13 different tick species generated rickettsial-specific amplicons in 10% (54) of total ticks tested. Only three tick species Rhipicephalus microplus, Hyalomma anatolicum, and H. dromedarii had evidence of infection with "Candidatus Rickettsia amblyommii" a result further verified using a rompB gene-specific quantitative PCR (qPCR) assay. The Hyalomma ticks also tested positive for the piroplasm, Theileria annulata, using a qPCR assay. CONCLUSIONS/SIGNIFICANCE: This study provides information about tick diversity in Pakistan, and pathogenic bacteria in different tick species. Our results showed evidence for Candidatus R. amblyommii infection in Rhipicephalus microplus, H. anatolicum, and H. dromedarii ticks, which also carried T. annulata.

Importation of exotic ticks and tick-borne spotted fever group rickettsiae into the United States by migrating songbirds.

Birds are capable of carrying ticks and, consequently, tick-transmitted microorganisms over long distances and across geographical barriers such as oceans and deserts. Ticks are hosts for several species of spotted fever group rickettsiae (SFGR), which can be transmitted to vertebrates during blood meals. In this study, the prevalence of this group of rickettsiae was examined in ticks infesting migratory songbirds by using polymerase chain reaction (PCR). During the 2009 and 2010 spring migration season, 2064 northward-migrating passerine songbirds were examined for ticks at Johnson Bayou, Louisiana. A total of 91 ticks was removed from 35 individual songbirds for tick species identification and spotted fever group rickettsia detection. Ticks were identified as Haemaphysalis juxtakochi (n=38, 42%), Amblyomma longirostre (n=22, 24%), Amblyomma nodosum (n=17, 19%), Amblyomma calcaratum (n=11, 12%), Amblyomma maculatum (n=2, 2%), and Haemaphysalis leporispalustris (n=1, 1%) by comparing their 12S rDNA gene sequence to homologous sequences in GenBank. Most of the identified ticks were exotic species originating outside of the United States. The phylogenetic analysis of the 71 ompA gene sequences of the rickettsial strains detected in the ticks revealed the occurrence of 6 distinct rickettsial genotypes. Two genotypes (corresponding to a total of 28 samples) were included in the Candidatus Rickettsia amblyommii clade (less than 1% divergence), 2 of them (corresponding to a total of 14 samples) clustered with Rickettsia sp. "Argentina" with less than 0.2% sequence divergence, and 2 of them (corresponding to a total of 27 samples), although closely related to the R. parkeri-R. africae lineage (2.50-3.41% divergence), exhibited sufficient genetic divergence from its members to possibly constitute a new rickettsial genotype. Overall, there does not seem to be a specific relationship between exotic tick species, the rickettsiae they harbor, or the reservoir competence of the corresponding bird species.

Knockdown of selenocysteine-specific elongation factor in Amblyomma maculatum alters the pathogen burden of Rickettsia parkeri with epigenetic control by the Sin3 histone deacetylase corepressor complex.

Selenocysteine is the 21st naturally-occurring amino acid. Selenoproteins have diverse functions and many remain uncharacterized, but they are typically associated with antioxidant activity. The incorporation of selenocysteine into the nascent polypeptide chain recodes the TGA stop codon and this process depends upon a number of essential factors including the selenocysteine elongation factor (SEF). The transcriptional expression of SEF did not change significantly in tick midguts throughout the blood meal, but decreased in salivary glands to 20% at the end of the fast feeding phase. Since selenoprotein translation requires this specialized elongation factor, we targeted this gene for knockdown by RNAi to gain a global view of the role selenoproteins play in tick physiology. We found no significant differences in tick engorgement and embryogenesis but detected no antioxidant capacity in tick saliva. The transcriptional profile of selenoproteins in R. parkeri-infected Amblyomma maculatum revealed declined activity of selenoprotein M and catalase and increased activity of selenoprotein O, selenoprotein S, and selenoprotein T. Furthermore, the pathogen burden was significantly altered in SEF-knockdowns. We then determined the global impact of SEF-knockdown by RNA-seq, and mapped huge shifts in secretory gene expression that could be the result of downregulation of the Sin3 histone deacetylase corepressor complex.

Molecular characterization of tick salivary gland glutaminyl cyclase.

Glutaminyl cyclase (QC) catalyzes the cyclization of N-terminal glutamine residues into pyroglutamate. This post-translational modification extends the half-life of peptides and, in some cases, is essential in binding to their cognate receptor. Due to its potential role in the post-translational modification of tick neuropeptides, we report the molecular, biochemical and physiological characterization of salivary gland QC during the prolonged blood feeding of the black-legged tick (Ixodes scapularis) and the gulf-coast tick (Amblyomma maculatum). QC sequences from I. scapularis and A. maculatum showed a high degree of amino acid identity to each other and other arthropods and residues critical for zinc binding/catalysis (D159, E202, and H330) or intermediate stabilization (E201, W207, D248, D305, F325, and W329) are conserved. Analysis of QC transcriptional gene expression kinetics depicts an upregulation during the bloodmeal of adult female ticks prior to fast-feeding phases in both I. scapularis and A. maculatum suggesting a functional link with bloodmeal uptake. QC enzymatic activity was detected in saliva and extracts of tick salivary glands and midguts. Recombinant QC was shown to be catalytically active. Furthermore, knockdown of QC transcript by RNA interference resulted in lower enzymatic activity, and small, unviable egg masses in both studied tick species as well as lower engorged tick weights for I. scapularis. These results suggest that the post-translational modification of neurotransmitters and other bioactive peptides by QC is critical to oviposition and potentially other physiological processes. Moreover, these data suggest that tick-specific QC-modified neurotransmitters/hormones or other relevant parts of this system could potentially be used as novel physiological targets for tick control.

Molecular characterization and functional significance of the Vti family of SNARE proteins in tick salivary glands.

Exocytosis involves membrane fusion between secretory vesicles and the plasma membrane. The Soluble N-ethylmaleimide-sensitive factor attachment proteins (SNAPs) and their receptor proteins (SNAREs) interact to fuse vesicles with the membrane and trigger the release of their sialosecretome out of the tick salivary gland cells. In this study, we examined the functional significance of the Vti family of SNARE proteins of blood-feeding Amblyomma maculatum and Amblyomma americanum. Vti1A and Vti1B have been implicated in multiple functional roles in vesicle transport. QRT-PCR studies demonstrated that the highest transcriptional expression of vti1a and vti1b genes occurs in unfed salivary glands, suggesting that elevated secretory vesicle formation occurs prior to feeding but continues at low rates after blood feeding commences. Vti1A and Vti1B localize to the secretory vesicles in unfed tick salivary glands in immunofluorescence microscopy studies. Knockdown of vti1a and vti1b by RNA interference resulted in a significant decrease in the engorged tick weight compared to the control during prolonged blood-feeding on the host. RNA interference of vti1a or vti1b impaired oviposition and none of the ticks produced eggs masses. Surprisingly, the double knockdown did not produce a strong phenotype and ticks fed normally on the host and produced egg masses, suggesting a compensatory mechanism exists within the secretory system which may have been activated in the double knockdown. These results suggest an important functional role of the Vti family of SNARE proteins in tick blood feeding and ultimately oviposition. Understanding the basic functions of the Vti family of SNARE proteins in salivary glands may lead to better ways to prevent tick attachment and transmission of tick-borne diseases.

Pilot study of providing online care in a primary care setting.

OBJECTIVE: To study the use of e-visits in a primary care setting. PATIENTS AND METHODS: A pilot study of using the Internet for online care ("e-visits") was conducted in the Department of Family Medicine at Mayo Clinic in Rochester, MN. Patients in the department preregistered for the service, and then were able to use the online portal for consultations with their primary care physician. Use of the online portal was monitored and data were collected from November 1, 2007, through October 31, 2009. RESULTS: During the 2-year period, 4282 patients were registered for the service. Patients made 2531 online visits, and billings were made for 1159 patients. E-visits were submitted primarily by women during working hours and involved 294 different conditions. Of the 2531 e-visits, 62 (2%) included uploaded photographs, and 411 (16%) replaced nonbillable telephone protocols with billable encounters. The e-visits made office visits unnecessary in 1012 cases (40%); in 324 cases (13%), the patient was asked to schedule an appointment for a face-to-face encounter. CONCLUSION: Although limited in scope, to our knowledge this is the largest study of online visits in primary care using a structured history, allowing the patient to enter any problem, and billing the patient when appropriate. The extent of conditions possible for treatment by online care was far-ranging and was managed with a minimum of message exchanges by using structured histories. Processes previously given as a free service or by nurse triage and subject to malpractice (protocols) were now documented and billed.

Impact of online primary care visits on standard costs: a pilot study.

As medical providers seek new ways to control costs, online visits have begun to receive serious consideration. The purpose of this study was to compare the odds of being a cost outlier during a 6-month period after either an online visit or a standard drop-in visit in a conventional medical office setting. Medical records of primary care patients (both adults and children) seen in a large group practice in Minnesota in 2008 were analyzed for this study. Two groups of patients were studied: those who had an online visit (N = 390) and a comparison group who had regular office care for same-day, acute visits (N = 376). Case types were classified as either complex or common, with common being defined as treatment for pinkeye, sore throat, viral illness, bronchitis, or cough. Outliers were defined as patients for whom standard costs exceeded the 75(th) percentile during a 6-month period after the index visit. Multiple logistic regression analysis was used to adjust for differences between groups. The percentage of online visitors who were cost outliers was 21.2 (versus 28.5 in the standard visit group). Median standard costs were $161 for online visits and $219 for same-day acute visits. The adjusted odds of being a cost outlier was lower for the online visit group than for the standard visit group (odds ratio [OR] 0.52, 95% confidence interval [95% CI] 0.35-0.77) after adjusting for number of visits in the previous 6 months, age, sex, and case type. Outpatient visits in the previous 6 months were positively related to outlier status (OR 1.23, 95% CI 1.17-1.29). Online visits appeared to reduce medical costs for patients during a 6-month period after the visit.

Impact of e-consults on return visits of primary care patients.

Virtual medicine is growing in importance as the cost of medical care rises and the potential for Internet applications expands. The purpose of this study was to evaluate the impact of e-consults (ECs) (also known as virtual specialty consultations) on the frequency of return visits for family medicine patients. Two groups of patients were compared: those for whom an EC was requested (n = 228) and a comparison group for whom face-to-face referrals occurred (n = 500). Two types of early return office visits were used as dependent variables: those within 2 weeks for any reason and those for the same reason. No significant difference was found in rates of early return visits for the same reason. The percent of return visits for any reason within 2 weeks was 38.2% for EC patients and 27.6% for patients receiving face-to-face specialist visits (p < .01). After adjusting for comorbidity, age, sex, and marital status, the odds of an early return visit for any reason after an EC were elevated (odds ratio, 1.88; confidence interval, 1.33-2.66; P < .01). E-consults by referral specialists were associated with increased odds of early return visits for primary care patients with a primary care provider.

Provider satisfaction with virtual specialist consultations in a family medicine department.

Virtual consultations (VCs) are being ordered by primary care physicians in 1 large multispecialty clinic, replacing face-to-face visits with specialists. Virtual consultations involve electronic communication between physicians, including exchanging medical information. The purpose of this study was to assess provider satisfaction with VCs via e-mail survey. Although approximately 30% of the 56 family medicine providers had not tried the VC system after it had been in place for over a year or said that they often forgot that VCs were an option, most of the providers surveyed (73%) felt that VCs provided good medical care. A majority felt that VCs are a cost-effective and efficient tool for our department (65%). Most specialists (81%) reported that VCs were an efficient use of their time, and 67% said that VCs were less disruptive than contacts by telephone or pager. Only 5% felt that VCs do not provide good medical care. Although several of our primary care providers have been enthusiastic about VCs, others have been reluctant to adopt this innovation. Specialists providing VCs tended to be supportive. This illustrates both the difficulty of incorporating e-health innovations in primary care practice and the potential for increased efficiency.

Illness severity and total visits in family medicine.

OBJECTIVE: The purpose of this study was to estimate the independent effect of clinical severity on visit utilization by family medicine patients so that disease management programmes can be targeted accurately and immediately towards patients most likely to benefit from them. DESIGN: A convenience sample of 698 primary care patients was analysed. All patients had been referred to a medical specialist. Utilization of all types of medical services including laboratory, radiology and ancillary services was used to classify patients as high-utilizers (the top 20%) or not high-utilizers. Patients were stratified into three severity categories based on point scores assigned to specific diseases. The diagnoses included in the Charlson severity index were used to score each patient and the Charlson point scores were used to measure severity. The odds of being a high-utilizer were adjusted for severity category and demographic variables. RESULTS: Severity was independently related to the odds of being a high-user (adjusted odds ratio = 2.7 for severity = 1 and 5.7 for severity = 2, with the reference category being severity = 0). Age was related to high-use in univariate analyses but not in multivariate analyses. CONCLUSIONS: Case management programmes in primary care practices should consider using disease severity to identify cases. Severity data can be abstracted by medical secretaries who review narrative problem lists as well as billing codes.

Age, obesity, and medical visits in family medicine.

The purpose of this study was to assess whether the relationship between obesity and use of medical visits is different for geriatric patients than for other adults. A retrospective analysis was conducted using medical records drawn from a large group practice in Rochester, Minnesota. Adult patients (n = 1715) were sorted into 2 groups (frequent visitors and others). Separate multiple logistic regression models were estimated for geriatric and non-geriatric patients. Patients who were 65 years of age or older with moderate comorbidity had elevated odds of being frequent visitors (odds ratio [OR] = 6.13, confidence interval [CI] = 3.27-11.49), compared to patients with no comorbidity. Body mass index (BMI), gender, and marital status were unrelated to visit frequency in the geriatric group. Younger patients with a BMI >or= 35 kg/m2 had greater odds of being frequent visitors compared to patients with normal body mass, after adjusting for comorbidity, age, marital status, and gender (OR = 1.96, CI = 1.31-2.92). ORs also were significantly greater for subjects with low (OR = 2.13, CI = 1.51-3.01) and moderate comorbidity (OR = 3.32, CI = 2.32-4.76) versus no comorbidity. In our sample of family medicine patients who were referred to specialists, BMI >or= 35 kg/m2 is an independent risk factor for frequent utilization of medical visits among adults who are younger than age 65, but not among geriatric patients. Comorbidity is strongly related to visit frequency among both older and younger adult patients.

Patient-centredness, self-rated health, and patient empowerment: should providers spend more time communicating with their patients?

OBJECTIVE: Patient-centred communication is often employed as a strategy for empowering patients. The purpose of this study was to investigate the relationship between a direct measure of patient empowerment, feeling that one is in control of one's own health and patient satisfaction with communication. DESIGN: A cross-sectional survey of family medicine patients was used to test the theory that, in primary care patients, empowerment is related to satisfaction with several aspects of communication after adjusting for health status, age and gender. Interviews were completed with 680 adult patients for whom complete data were available. RESULTS: Multiple logistic regression analysis revealed that being highly satisfied with overall communication [adjusted odds ratio (AOR)=2.08], explanations (AOR=2.04), listening (AOR=2.63), use of understandable words (AOR=2.41) and involvement in decisions (2.34) were positively associated with empowerment. Self-rated health was more strongly related to empowerment than satisfaction with communication in every model tested (AORs ranged from 2.8 to 3.0). CONCLUSIONS: Reliance solely on patient-centred communication to promote empowerment may be insufficient as well as costly. Instead, improved one-to-one communication between patients and providers should be reserved for clinically complex and urgent situations. For other health matters, referral of patients to community health promotion and education programmes should be considered because this may offer a lower-cost approach to empowerment.